2 CAIN ROAD SYSTEM PUMPING RECORD 1-24-22 Commonwealth of Massachusetts
City/Town of salem
System Pumping Record
Form 4
AP..5 lf DEP has provided this form for use by local Boards of Health.Other forms may be used,but the information must be
substantially the same as that provided here.Before using this form,check with your local Board of Health to determine the form
they use.The System Pumping rtecord must be submitted to the local Board of Health or other approving authority within 14
days from the pumping date in accordance with 310 CMR 15.351.
A. Facility Information
1. System Location:
2 Cain Rd
Address
Salem MA 01970
City/Town State ZIioCode
2. System Owner:
Camp Fire North Shore
Name
2 Cain_ Road,
Address(if different from location)
Salem MA 01970
City/Town State Zip Code
9787457200 x
Telephone Number
B. Pumping Record
1. Date of Pumping Date 01/24/2022 2. Quantity Pumped. Gaallloness o 000i)
3. Component: ❑ Cesspool(s) F)7( Septic Tank Tight Tank Grease Trap
❑ Other(describe):
4. Effluent Tee Filter present? ❑Yes❑X No If yes, was it cleaned? ❑Yes 0 No
5. Observed condition of component pumped:
Normal watnr le-a]- 9i-n bottom sl-udge 6in tQp golids Bath baffles are intant-
e used with a iiiter. Cover(s) secured. No 3ra party paperwork tilled.
6. System Pumped By:
Michael Graham
Name Vehicle License Number
Wind River Environmental, LLC, 577 Main Street, Ste #110, Hudson, MA 01749
Company
7. Location where contents were disposed:
163 Western Ave, Gloucester, MA 01930
01/24/2022
Signature of Hauler Date
Signature of Receiving Facility(or attach facility receipt) Date
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